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Long Haul Trucking Questionnaire

Posted By on 09-02-2021
Long Haul Trucking Questionnaire

Whether you’re a large trucking company with a fleet of trucks or a single owner operator, the information required to get insurance will be exactly the same and in this post you’ll find the Long Haul Trucking questionnaire that will provide the details required to start the process.

Providing as much driver and cartage information as possible will help reduce premiums and the following questionnaire covers all of the details that enable BlueCircle to quote you accurately and get you properly insured.


Name of applicant:

Address:

Phone:

Email:

Website:

Contact Name & Title:

Years in business:

Year’s similar experience:

Gross receipts: $

What percent of drivers are lease operators?:

Current Insurance Company:

Expiry Date: 

Full description of operations:

☐  Contract Carrier        ☐  Common Carrier        ☐  Private Carrier        ☐  Corporation        ☐  Freight Forwarder

 Required Information:  Please include the information below when returning the completed questionnaire:

☐  Loss Run                 ☐  Carrier Profile               ☐   Fuel Tax Reports            ☐   Driver Abstracts/MVR’s

☐  Drivers List              ☐   Vehicle List                  ☐   Telematics Info               ☐  Lease Operator Contract

 

Position Name Years in Position
President    
Manager    
Claims Manager    
Maintenance Manager    

 

 Claims Details:

*3-6 year Loss Run / Experience Letters also need to be included.

Driver # Date of claim Claim details CGL Details Cargo Details Total Payout $
           
           
           
           
           
           

 

 

 Driver Details:

Name Birth Date Year driving Accident Driver’s Lic # Date Hired
  DD/MM/YY Similar vehicle Y/N    
           
           
           
           
           
           
           

Which drivers are considered Lease Operators (*)

 Driver Convictions:

Name Conviction Type Date Convicted If Speeding
      KM’s over limit
       
       
       
       
       

 

 

 Driver Controls:


 References and Licensed checked? Yes  ☐   No ☐

Please outline your driver screening process: Click here to enter text.

Are operating records (MVRs) regularly checked? Yes ☐  No ☐     how often? Click here to enter text.

Do you hire underage operators (under 25 years old / less than 3 years driving experience) Yes ☐    No ☐

What is the minimum requirement for the number of years the driver has been licensed? Click here to enter text.

 

Please describe your driver onboarding process: Click here to enter text.

Are drivers provided an Employee/Safety policies and procedure manual? Yes ☐   No ☐

 

 Fleet Safety:


 Is there is a written Loss Control Program in place?  Yes ☐   No ☐

 

Are driver safety meetings held regularly?   Yes ☐  No    ☐             How often?

 

Has the driver been provided with protocols for reporting accidents?  Yes ☐  No ☐ :

 

Where vehicles parked overnight and security measures are: Address:

 

☐  Fenced Yard                              ☐    Guard Dog                            ☐  Well Lighted

 

☐  Locked Gate                              ☐    Security System                    ☐  Watchman

 

 

 Maintenance & Equipment:


 Is there is an equipment/vehicle maintenance program?  Yes ☐  No ☐

 

Who completes vehicle repairs?

 

Are maintenance records kept per vehicle?   Yes ☐  No ☐

 

Are vehicles equipped with anti- Theft devices? Explain:

 

  Filings:

Are filings required:  Yes ☐   No ☒     MC#             DOT#

Legal Name on the filing: 

Address on filing:  Same as above  ☐     OR

  Radius of Operations: Please provide IFTA reports

Furthest destination in Canada

Furthest destination in the USA

  KM Split:

Canada   USA  
Radius Percentage must add to 100% Radius Percentage must add to 100%
% within 250 km   % within 250 km  
% 251-750 km   % 251-750 km  
% 751 – 1500 km   % 751 – 1500 km  
% 1501 – 4000 km   % 1501 – 4000 km  
% over 4000 km   % over 4000 km  

 

  Vehicle List:      Are all vehicles registered to the applicant   Yes ☐   No ☐

Units # Year Make/Model Vin# Purchase Date LPN $ ACV $
1            
2            
3            
4            
5            

 

  Trailer List:

  Is NON OWNED TRAILER required?   Yes ☐ No  ☐          Trailer Limit $  Click here to enter text.

Units # Year Make/Model Vin# Purchase Date LPN $ ACV $
1            
2            
3            
4            
5            

 

  • Identify any refer units

 

Cargo List:          Cargo limit required $

 

Do you use a bill of lading? Yes ☐   No ☐

 

Complete for all commodities carried

Types of Non Target Cargo FTL – Full Load value $ LTL – Less Than Load value $ %
General Freight  $  $ %
Office Supplies      
Grocery Items      
Plastic Products      
Paper Products      
Building Materials      
Machinery (NO VEHICLES/AUTOS)      
Auto Parts      
Bakery Products      
Furniture      
Appliances      
Packaged Meat      
Frozen Food/ Cooled Produce      
Milk Products      
Steel      
Other:      
Other:      
Paint      
Batteries      
Household Use Chemicals      
Air Bags      
Glue      
Electronics      
Beer      
Liquor      
Sea Food      
Pharmaceutical Products      
Copper      
Aluminum      
Garments      
Other:      
       
TOTAL %      

 

Do you haul any hazardous goods as defined by the Hazardous Goods Act?  Yes ☐  No  ☐

 

List all Placard numbers:

 

Coverages / Deductibles:   (This section to be completed by broker)

 

Coverages Limit Deductible
Automobile
Third Party Liability    
Collision    
Comprehensive    
All Perils    
SEF 44    
SEF 20    
SEF 40    
     
APD
APD Limit: Trucks & Trailers    
All Perils    
     
Cargo
Cargo Limit    
Warehouseman’s Liability    
Target Inclusion    
Towing, Storage, Debris Removal    
Refer Breakdown    
     
General Liability
CGL Limit    
TTL    
Crane Lift Operator Liability    
Conditional Release Bond    
     
Per Occurrence Deductible    

 

Notes: 

 

 

 

Name of Insured:

 

Name of Broker: Dan Whaley  Ph: 403-770-0134     Email: [email protected]

 

Date:  

 

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